Diagnosis of latent tuberculosis infection (tuberculosis screening) in HIV-uninfected adults
- Dick Menzies, MD, MSc
Dick Menzies, MD, MSc
- Professor of Medicine and of Epidemiology & Biostatistics
- Montreal Chest Institute, McGill University
Treatment of individuals with active tuberculosis (TB) is the first priority for tuberculosis control; an important second priority is identification and treatment of individuals with latent tuberculosis infection (LTBI) [1-3].
In most individuals, Mycobacterium tuberculosis infection is contained initially by host defenses, and infection remains latent . However, latent infection has the potential to develop into active disease at any time. Identification and treatment of latent tuberculosis infection can reduce the risk of development of disease by as much as 90 percent  and so has the potential to protect the health of the individuals as well as the public by reducing the number of potential sources of infection [6,7].
There are two major tests for identification of latent tuberculosis infection: the tuberculin skin test (TST) and the interferon-gamma release assay (IGRA) [8,9]. Both tests evaluate cell-mediated immunity.
Use of TST for diagnosis of LTBI in HIV-uninfected patients will be reviewed here. Management of LTBI for patients with HIV or receiving tumor necrosis factor-alpha inhibitors is discussed in detail separately, as are issues related to TB screening in children and treatment of LTBI in HIV-uninfected patients. (See "Treatment of latent tuberculosis infection in HIV-infected adults" and "Latent tuberculosis infection in children" and "Tumor necrosis factor-alpha inhibitors and mycobacterial infections" and "Interferon-gamma release assays for diagnosis of latent tuberculosis infection".)
INDICATIONS FOR TESTING
The goal of testing for latent tuberculosis infection (LTBI) is to identify individuals who are at increased risk for the development of tuberculosis (TB) and therefore would benefit from treatment of LTBI (table 1 and table 2); these include [10-13]:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for Latent Tuberculosis Infection in Adults: US Preventive Services Task Force Recommendation Statement. JAMA 2016; 316:962.
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- Marais BJ, Gie RP, Schaaf HS, et al. The natural history of childhood intra-thoracic tuberculosis: a critical review of literature from the pre-chemotherapy era. Int J Tuberc Lung Dis 2004; 8:392.
- Linas BP, Wong AY, Freedberg KA, Horsburgh CR Jr. Priorities for screening and treatment of latent tuberculosis infection in the United States. Am J Respir Crit Care Med 2011; 184:590.
- Canadian Tuberculosis Standards, 7th Edition 2013. http://www.respiratoryguidelines.ca/tb-standards-2013 (Accessed on November 16, 2016).
- Patel S, Parsyan AE, Gunn J, et al. Risk of progression to active tuberculosis among foreign-born persons with latent tuberculosis. Chest 2007; 131:1811.
- Comstock GW, Edwards LB, Livesay VT. Tuberculosis morbidity in the U.S. Navy: its distribution and decline. Am Rev Respir Dis 1974; 110:572.
- Cheng MP, Abou Chakra CN, Yansouni CP, et al. Risk of Active Tuberculosis in Patients with Cancer: A Systematic Review and Meta-Analysis. Clin Infect Dis 2016.
- Stead WW, To T, Harrison RW, Abraham JH 3rd. Benefit-risk considerations in preventive treatment for tuberculosis in elderly persons. Ann Intern Med 1987; 107:843.
- Kopanoff DE, Snider DE Jr, Caras GJ. Isoniazid-related hepatitis: a U.S. Public Health Service cooperative surveillance study. Am Rev Respir Dis 1978; 117:991.
- Sterling TR, Villarino ME, Borisov AS, et al. Three months of rifapentine and isoniazid for latent tuberculosis infection. N Engl J Med 2011; 365:2155.
- The Online TST/QFT Interpreter. Version 2.0. http://www.tstin3d.com/index.html (Accessed on September 24, 2010).
- Pai M, Kunimoto D, Jamieson F, Menzies D. Diagnosis of Latent TB Infection. In: Canadian Tuberculosis Standards, 7th ed, Menzies D (Ed), Canadian Lung Association and Public Health Agency of Canada, Ottawa 2013.
- Hoppe LE, Kettle R, Eisenhut M, et al. Tuberculosis--diagnosis, management, prevention, and control: summary of updated NICE guidance. BMJ 2016; 352:h6747.
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- Menzies D, Doherty TM. Diagnosis of latent tuberculosis infection. In: Reichman and Hershfield's Tuberculosis, a comprehensive international approach, Raviglione MC (Ed), Informa Healthcare USA, New York 2006. p.215.
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- Froeschle JE, Ruben FL, Bloh AM. Immediate hypersensitivity reactions after use of tuberculin skin testing. Clin Infect Dis 2002; 34:E12.
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- Centers for Disease Control and Prevention. Guide to Vaccine Contraindications and Precautions. Department of Health and Human Services. Available at: http://www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf
- Menzies D. Interpretation of repeated tuberculin tests. Boosting, conversion, and reversion. Am J Respir Crit Care Med 1999; 159:15.
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- von Reyn CF, Horsburgh CR, Olivier KN, et al. Skin test reactions to Mycobacterium tuberculosis purified protein derivative and Mycobacterium avium sensitin among health care workers and medical students in the United States. Int J Tuberc Lung Dis 2001; 5:1122.
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- Richard Menzies, MD, MSc, personal communication.
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- INDICATIONS FOR TESTING
- Recent exposure
- Healthcare workers
- Immigrants (from high-incidence to low-incidence countries)
- Underlying conditions that increase risk of progression
- - General principles
- - Age and risk of drug-induced hepatitis
- - Cancer and risk of reactivation
- TOOLS FOR LTBI TESTING
- Selection of test
- Interferon gamma release assays
- Tuberculin skin test
- - Performing the TST
- Adverse reactions
- - Interpreting the TST
- Negative tests
- - False-negative tests
- - Treating negative tests
- Positive tests
- - False-positive tests
- - Treating positive tests
- Healthcare workers
- Allergic reactions
- Managing referrals
- - Repeat and serial testing
- Repeat TST interpretation
- - Booster response
- - TST conversion
- - Definition of positive repeat TST
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS